Provider Demographics
NPI:1467430207
Name:MOORE, MARLIN KEM (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARLIN
Middle Name:KEM
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 FT RICHARDSON AVE
Mailing Address - Street 2:BUILDING 1007
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:271 FT RICHARDSON AVE
Practice Address - Street 2:BUILDING 1007
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76908
Practice Address - Country:US
Practice Address - Phone:325-654-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4810103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service